Working Document. Five year Cancer commissioning Strategy for London. Page 1 of 50

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1 Working Document Five year Cancer commissioning Strategy for London Page 1 of 50

2 Table of contents A Executive summary 3 B Introduction 5 C Cancer Commissioning Strategy for London 2014/ / Prevention Cancer screening Early diagnosis and awareness Reducing variation and service consolidation Chemotherapy Radiotherapy Patient experience Living with and beyond cancer End of life care 43 D The enablers to deliver the strategy 45 E Summary and assessment of recommendations made by each workstream 46 F Conclusion 50 Page 2 of 50

3 Five year Cancer Commissioning Strategy for London A. Executive summary Every year more than 30,000 Londoners will receive a cancer diagnosis 1. As treatments and care improve, greater numbers of people are living with and beyond cancer. In London the number of people living with and beyond cancer is more than 200,000 and this is expected to double by Cancer and how it is managed is therefore changing as treatments advance and survival rates increase; for many patients, cancer is a condition they live with and manage on an on-going basis similar to other long term conditions. Despite the fact that more people are surviving cancer than ever before, mortality and survival rates vary significantly between London boroughs: fourteen London CCGs have lower one year survival rates than the England average mortality rates than the England average 3. Cancer is the second leading cause of death across the capital and this rises to the leading cause of premature [or under 75] death 4. London is a world class city with the aim of being the best big city in the world 5 and yet it cannot currently claim world class cancer outcomes nor can it claim to care for cancer patients in a way that puts them and their needs first. Patients in London are still diagnosed when their cancer is at a later stage than European counterparts meaning successful treatment is less likely. Across the capital, between 25 and 30per cent of cancer diagnoses are made in Accident and Emergency (A&E). Late stage cancers can impact the type of treatment available to the patient: for example resection rates for lung cancer are dependent on the tumour being at an early stage. Furthermore, variation in care and treatment following diagnosis can lead to poorer patient outcomes and patient experience. Simply reviewing the length of stay and readmission rates for colorectal cancer patients across London paints a picture of the enormous variation in patient experience and outcomes depending on where an individual is diagnosed, receives treatment and follow up care 6. The National Cancer Patient Experience Survey brings home the extent of reported poor patient experience, with nine out of the 10 worst reported hospitals for cancer patient experience being in London a position London holds year on year data, Encore Cancer Analysis System 2 Estimated for London (SHA) based on population estimates and Maddams J, Uttley M, Moller H. Projections of cancer prevalence in the United Kingdom, British Journal of Cancer 2012; 107: Figures exclude non melanoma skin cancer 3 Cancer Research UK Local Statistics: Data from ONS/ London School of Hygiene and Tropical Medicine (2010) 4 As documented in London borough Joint Strategic Needs Assessments 5 Boris Johnson s aim for London 6 Please see Reducing Variation and Service consolidation section of the strategy 7 pdf Page 3 of 50

4 Despite great progress in implementing the 2010 Model of Care 8, there is more we can do to ensure implementation of the recommendations is accelerated. Additionally since the development of the Model of Care, new evidence and developments have been made to inform national thinking on issues such as the early detection of cancer and supporting patients after cancer treatment. Taking the two elements into account, London should be able to drive up cancer outcomes to match best in world and that all Londoners, no matter where they live in London, receive excellent care. This refresh and re-state of the Model of Care provides a five year vision and sets out the priorities across London for transforming cancer services. For London to make a demonstrable improvement in transforming cancer services improving outcomes and patient experience public health teams, CCGs, NHS England, the Integrated Cancer Systems and the voluntary sector will need to work together in a new way. This will be a challenge but is deliverable. 8 Page 4 of 50

5 B. Introduction In 2009, the Case for Change 9 identified many of the challenges facing London s cancer services: late diagnosis of cancers with many cancers diagnosed at a late stage when successful treatment is less likely; variability in cancer outcomes across London for common cancers; variability in cancer outcomes across London for rare and more complex cancers; poor patient experience: nine of the ten worst providers in England for patient experience are in London and this has not changed since 2009; and, rising costs of cancer care (which more recent modelling estimates the total cost associated with patients receiving cancer services to be around 2.2bn and rising). The Model of Care was subsequently developed in 2010 by London s cancer community and proposed robust, clinically-led solutions to enable improvements to be made in the capital s cancer services. Setting out 104 recommendations across 13 care pathways, the Model of Care s key recommendations were to: Help diagnose cancer earlier Improve patient care and reduce inequalities in access to and uptake of services Improve patient outcomes Improve patient experience. Since 2010, London s providers and commissioners have worked to implement the recommendations set out in the Model of Care. Significant changes have included the development of the two integrated cancer systems London Cancer and London Cancer Alliance - which bring together London s 28 acute and tertiary care providers cancer providers to deliver coordinated and integrated care along the whole patient pathway. April 2013 brought changes to the NHS with new commissioning arrangements: CCGs have responsibility for the commissioning of common cancer services as well as early diagnosis, services for patients living with and after cancer as well as end of life care. NHS England has responsibility for the direct commissioning of specialist services including chemotherapy and radiotherapy, primary care and cancer screening. Public Health teams within Local Authorities take on responsibility for prevention and population awareness of cancer signs and symptoms. 9 Page 5 of 50

6 Three years into delivering the Model of Care, costs are escalating, budgets are becoming tighter and patient experience remaining stubbornly poor Having a clear, refreshed cancer strategy will ensure that progress on implementing the Model of Care, and new developing cancer improvements, is accelerated. It will be critical that this is underpinned with an understanding of how commissioners will need to commission different aspects over the five years, and any significant investments that may be required or savings that may be achieved through the implementation of this strategy. This restatement of the Model of Care sets out proposed priorities for commissioners over the next five years. It needs to be reiterated that the Model of Care still stands and progress is expected to continue implementation of the recommendations. This refreshed strategy reflects those areas of importance for all commissioners and it is hoped commissioners will rally behind in order to transform cancer outcomes. The strategy sets out an assessment of proposed interventions prioritised against: patient outcomes; patient experience; and, readiness of each intervention for implementation. A full summary of the recommendations can be found at the end of the strategy document. It will be for commissioners to determine how, and from whom, they wish to commission services on behalf of their patients. Further modelling work is currently being undertaken to support investment decisions and local evaluation and implementation plans will need to be developed. By setting out a five year view of the priorities for cancer, the strategy aims to make the compelling case for transforming cancer services across London so that every Londoner receives a world class experience from prevention, through early detection to treatment, subsequent support and to end of life care. In this way, it is believed more than 1000 extra Londoners lives can be saved. This strategy is a refresh of the Model of Care which also includes new evidence and sets out new developing ideas setting out the compelling case for commissioners to support the transformation of cancer services across London. Developing the strategy Discussion at meetings of the Cancer Commissioning Board (CCB) and the Cancer Clinical Leadership Advisory Group (CCLAG) have reiterated the importance of having a strategic and planned approach for cancer to enable decision making by commissioners to support the delivery of the Model of Care and further proposals to support the transformation of cancer services in London. This will ensure that the Model of Care implementation is conducted in an appropriately phased way over a two to five year period and that new recommendations for improvement are built into commissioner and provider plans. Page 6 of 50

7 At the same time, NHS England s The NHS belongs to the people: A Call to Action 10 has launched. This is a public, staff and stakeholder consultation to determine NHS priorities (across all disease areas) moving forward in order to meet rising demand and expectations of the NHS. This plan for cancer will align with the national Call to Action work, ensuring that the importance of bringing about improvements in cancer services across London is recognised as a priority with all key stakeholders, including new commissioning organisations. Through engagement work in 2012/13 and 2013/14 with CCGs and GPs, a number of key insights were gained as to what is important from a primary care perspective and as clinical commissioners. These insights are summarised in Table 1 below. Many reinforce the recommendations made in the Model of Care and others, for example the importance of understanding co-morbidities and specific areas around communication, provide new insights that will need to be reflected in the refreshed strategy. Table 1: CCG priorities as recorded at the 2012/13 engagement events Clinicians, commissioners and providers have been involved throughout the development of the five year commissioning strategy. Each of the workstreams comprises a steering group that oversees the development of the five year strategies with clinicians, commissioners and providers represented on these groups. Each workstream presented its five year strategy at an extended meeting of the Cancer Clinical Leadership advisory group in November 2013 for clinical feedback and input. Pathway chairs from both ICSs were asked to join this meeting to widen the cancer clinical representation and engagement. The Pan London Cancer User Partnership consists of cancer patients and carers from across London which meets regularly to provide feedback as to the cancer programme. Each workstream, during development, has been taken to the Partnership meeting for input during the 2013/14. A sub group of the Cancer Commissioning Board met regularly between September and December 2013 to oversee the development of the five year strategy and to 10 Page 7 of 50

8 ensure progress was made. Again clinicians, commissioners and both ICSs made up this steering group. The Cancer Commissioning Board received the five year strategy at its December 2013 meeting and was supportive of the direction of travel. Page 8 of 50

9 C. Cancer Commissioning Strategy for London: 2014/ /2020 This strategy has been developed by reviewing each of the key areas of work within the Transforming cancer services for London programme across London. It has been a collaborative development between clinicians directly associated with each area providing clinical expertise; CCG representatives through recent engagement work and the contributions of recognised GP cancer leads; representatives from the Integrated Cancer Systems linking into the clinical pathway groups; commissioners from Public Health England; and commissioners from NHS England. The key areas of focus are: 1. Early detection and awareness 2. Reducing variation in secondary care (including service consolidation) 3. Patient experience 4. Chemotherapy 5. Radiotherapy 6. Living with and beyond cancer 7. End of Life care Patient experience is, of course, central to the development of all workstreams and interventions are assessed against their impact on patient experience. However, because of the continuing poor patient experience in London, it has been identified as a workstream in its own right to ensure an on-going focus. Cancer screening is key to the early detection and awareness programme. The screening team, funded by Public Health England and hosted by NHS England, has been developing a strategy for screening. A summary of this strategy is included within this document. Additionally because of the intrinsic role of prevention in reducing mortality from cancer, recommendations are set out below as to what needs to be done in this area. The section on prevention has been written in collaboration with public health consultants leading to the recommendations set out below. The document will follow the patient pathway from prevention, early diagnosis and awareness including screening to end of life care. Page 9 of 50

10 1. Preventing Londoners from developing cancers amenable to changes in lifestyle Recommendations for commissioners: Preventing cancer is the responsibility of each local health economy by helping people through specific programmes and multi-agency partnerships on reducing tobacco use, healthy eating, exercise, diet, alcohol harm reduction and especially smoking cessation, with particular focus on vulnerable groups. It is recommended that CCG commissioners: - Commission well-evidenced primary prevention programmes focussed on the key risk factors linked to London s biggest diseases. There is evidence that there are a number of preventable or modifiable behaviours that may reduce an individual s risk of getting cancer. It is estimated that 43per cent cancers are attributed to lifestyle and environmental factors 11 meaning there is great potential to stop Londoners from developing cancer in the first place, delivering better patient experience and savings for the NHS. 12 The British Journal of Cancer review looked at the numbers of cancers attributable to fourteen lifestyle and environmental factors in the UK in These factors include tobacco, alcohol, diet, being overweight and/ or obese, and levels of physical exercise. It is believed that more than 100,000 cancers equivalent to one third of all those diagnosed in the UK each year are caused by smoking, unhealthy diets, alcohol and excess weight. Smoking is by far the most important risk factor for cancer responsible for 19.4per cent of all new cancer cases in 2010 equating pretty much to one in five cancers per cent of lung cancers are associated with cancer. The most significant action that could be taken in London to prevent cancer is to help smokers to stop and to prevent young people from starting smoking in the first place. There are a number of local and pan-london activities that would support this ambition, for instance: Securing continued investment in evidence based stop smoking services and ensuring that these are promoted widely to all smokers, but particularly those in priority groups e.g. pregnant women, people with long term conditions. Ensuring all local health care professionals/practitioners are trained in delivering Very Brief Advice 14 on smoking and know where to refer or signpost people to if they are interested in taking action to stop or reduce their smoking. 11 The Fraction of Cancer Attributable to Lifestyle and Environmental Factors in the UK in 2010, BJC; Volume 105, Issue S2 (Si-S81) Published 6 December 2011, Dr D Max Parkin; with Lucy Boyd, Professor Sarah C Darby, David Mesher, Professor Peter Sasieni and Dr Lesley C Walker 12 The Fraction of Cancer Attributable to Lifestyle and Environmental Factors in the UK in 2010, BJC;Volume 105, Issue S2 (Si-S81) Published 6 December 2011, Dr D Max Parkin; with Lucy Boyd, Professor Sarah C Darby, David Mesher, Professor Peter Sasieni and Dr Lesley C Walker Page 10 of 50

11 Ensuring all secondary care providers follow recent NICE guidance 15 in relation to the identification and referral of smokers, cessation and access to stop smoking medications. This also includes ensuring that all health care facilities (buildings and grounds) are smoke-free. Ensuring that individuals who are presenting with cancer symptoms and those who receive a cancer diagnosis are asked about smoking behaviours, informed of the help available to help them to stop and provided with the necessary support. Next in importance are reductions in obesity in women and in heavy alcohol consumption particularly in men, and certain other dietary changes including increasing consumption of fruit and vegetables and fibre, and reducing high consumption of meat and salt. Each of these four main strategies for cancer control would also substantially reduce the burden of other non-communicable diseases, particularly cardiovascular, diabetic, renal and hepatic disease. High exposure to ultraviolet (UV) light can cause malignant melanoma in people with all skin types but people with fair and/or freckly skins are at higher risk. UV exposure includes strong sunlight and sun beds. Protecting the skin from strong UV light through the use of appropriate sunscreens or sun avoidance reduces the chances of getting malignant melanoma. Prevention offers the most cost effective long term strategy for the control of cancer and earlier detection will improve prognosis. Primary care has the potential and opportunity to coordinate care for better population health and wellbeing outcomes. As the commissioner of Primary Care, NHS England (London region) aims to provide an easily accessible route to care for individuals that is orientated toward self-reliance and self-determination with an emphasis on health promotion and illness prevention. It is currently working on a longer term transformation of primary care programme in order to ensure that primary care is proactive in empowering individuals to improve health literacy and creates environments in which individuals, families and communities know and can lead healthy lives. Commissioning for prevention is one potentially transformative change that CCGs can make, together with Health and Wellbeing Boards and their other local partners. Reallocating resources to fund priority prevention programmes has the potential to support the prevention of a number of diseases including 43per cent of all cancer cases. To support this CCGs, local government, schools, providers, employers and others will need to work together to optimise the full range of resources there are available. Implemented systematically, the evidence suggests prevention programmes can be important enablers for reducing acute activity and capacity over the medium term but currently only about 4 per cent of the total NHS budget is spent on prevention Page 11 of 50

12 2. Cancer screening Recommendations for commissioners in years one and two: It is recommended that NHS England Screening commissioners: - Work closely with Local Authority Public Health teams to ensure screening is a priority in Joint Strategic Needs Assessments and Health and Wellbeing strategies. - Review contractual levers to incentivise coverage and uptake with screening providers. - Support the rollout of BowelScope programme Commission the age extension for bowel screening. It is recommended that NHS England Primary Care Commissioners: - Develop education programmes in partnership with CCGs and the NHS England/Public Health England Screening team. - Review the contractual levers to encourage uptake and coverage through primary care. It is recommended that CCG commissioners and individual practices: - Work with NHS England screening commissioners to facilitate the pathway from screening to treatment and achieve the 62 day pathway. - Include screening in their educational activities for primary care. - Nominate screening leads to champion and facilitate messaging. - Work with local community groups (facilitated through links with local authority public health teams) to deliver messages about screening. It is recommended that Local Authority commissioners: - Work with other commissioners to improve public knowledge and understanding of screening programmes. - Continue to commission cervical sample taking through community based family planning facilities. London has the lowest coverage and uptake for cancer screening in England with large variation in take up between boroughs and inequalities between socioeconomic and ethnic groups. There is evidence of poor public awareness and understanding of screening programmes in some groups across London 18. Patient experience is also not systematically measured across all screening services. New cancer screening programmes such as BowelScope for 55 years olds are being introduced across London offering new opportunities to prevent and diagnose cancers earlier. To maximise the impact of new and existing programmes, it is vital uptake is optimised so that more people are diagnosed at an early stage or prevented from developing cancer through the identification of pre-cancerous conditions. Over the 17 (Bowel Scope is a new screening programme inviting people around their 55th birthday for a Flexible Sigmoidoscopy examination of the lower bowel) 18 Cancer Awareness Measures undertaken across London Page 12 of 50

13 course of this five year strategy the aim for cancer screening must be to ensure all Londoners have a good understanding of the benefits of screening and are thus able to make an informed choice about participating in screening. Commissioners will need to commission high quality, patient focussed screening programmes demonstrating that they meet or exceed national standards and targets across all screening programmes and communities in London. The cancer screening programme for London will: increase public awareness and engagement with cancer screening programmes across all communities; increase engagement of primary care and improve reliability of data; improve quality, capacity and patient experience of provider services to optimise coverage and uptake; and, facilitate high quality research to further inform strategies to improve coverage and uptake in London. Page 13 of 50

14 3. Early diagnosis and awareness Recommendations for commissioners in years one and two It is recommended that Public Health England commissioners: - Continue investment in national Be Clear on Cancer campaigns which have shown to be effective in increasing referral rates. - Explore contractual levers with dentistry and pharmacy that can be used to increase cancer awareness messaging and sign posting. It is recommended that Primary Care commissioners: - Mandate that two of the annual six pharmacy marketing campaigns are used for cancer awareness. It is recommended that Public Health commissioners from Local Authorities and CCG commissioners: -Commission locally-developed awareness campaigns to improver earlier detection of cancer, for example the Get to know Cancer pop up shop and cancer activist programmes. It is recommended that CCG commissioners: - Continue to invest in GP cancer leads that provide local leadership and coordination for early detection activities. - Backfill GP sessions to enable GPs to attend training on using the cancer decision support tool. - Commission along the best practice guidelines developed for the early detection of bowel, lung, ovarian and, when ready, vague abdominal symptoms and blood in urine. - Commission additional endoscopy capacity for lower gastrointestinal cancers and to only commission from JAG accredited providers. For many cancers, the earlier a cancer is diagnosed and treated, the greater the prospect of survival and improved quality of life. Achieving earlier diagnosis has the greatest potential for improving outcomes and survival for cancer patients in London. The implications for increasing earlier detection include increasing the volumes of patients referred for diagnostics. The case for change notes that raising survival rates in England to match the best in Europe could save approximately 1000 lives per year in London and indeed this may be a low estimate. Recent modelling undertaken by Deloitte Monitor identified an additional 1470 patients could be diagnosed at a time when their cancer outcome could be improved. Across London, 25per cent - 30per cent cancer diagnoses will occur in A&E where the potential for a successful outcome is much lower. A percentage of these will enter A&E as a result of direct referral from the GP to enable fastest access for the patient into secondary care. Acute Oncology Services, as detailed in section four, will enable both a better patient experience and outcomes for these patients. Page 14 of 50

15 For early detection and awareness, the refreshed strategy seeks to tackle each element of the pathway that can lead to a delay in diagnosis. From public delay in seeking medical advice due to fear, worry or a lack of knowledge of symptoms, to GP delay that stops prompt and appropriate referrals, to system delay that slows the time taken for a cancer diagnosis to be reached. Given the significant inequalities that exist across London, driven by factors including deprivation, ethnicity, single living households, age, it is also recommended that locally driven specific interventions target local inequalities. The strategy prioritises the most common cancers in London where the potential for impact is greatest 19 : Bowel Lung Breast. It also prioritises those where national estimates show large numbers of lives could be saved through earlier diagnosis: Ovarian Oesophago-gastric. Melanoma or skin cancer is also prioritised because of the growing incidence and mortality rates 20. Although one of the most common cancers in men, prostate cancer is not prioritised here because of the lack of reliability of the current diagnostic for prostate cancer, the PSA test, and as London s survival rates are comparable to other parts of the country. 1. Public delay Fear at what the doctor might find, worry about wasting the GP s time, lack of knowledge about specific cancer signs and symptoms and inability to make a GP appointment at a suitable time can all contribute to a public delay in getting medical help. A series of initiatives are proposed to tackle this. Awareness campaigns of common signs and symptoms through further roll out and promotion of the national Be Clear on Cancer campaign is one approach to raising the public s understanding of signs and symptoms; one key priority area is raising awareness of breast cancer symptoms in women aged 70 and over as well as increasing the voluntary uptake of the breast cancer screening programme in this older population. Additionally there is a need for local specific campaigns that target areas of inequalities and high cancer incidence. The Get to know cancer campaign utilises empty retail space on busy shopping streets to deliver a pop up shop staffed by cancer nurses and supported by volunteer Cancer Activists who are trained to talk about common cancer signs and symptoms. Evaluated by Kings College London, 19 Abdel-Rahman et al, BJC Supplement December Cancer Research UK: Page 15 of 50

16 the shops encourage people to talk about cancer in a non-clinical environment conveniently located in the community 21. By profiling the fact that cancer survival rates have more than doubled over the last forty years and that earlier diagnosis can increase the chances of successful treatment, the Get to know cancer campaign works to target the fear and fatalism about cancer that can stop the public visiting the GP when they first notice something wrong. Many healthcare providers will routinely come into contact with the public and those at higher risk of cancer providing an ideal opportunity to both educate the public about cancer signs and symptoms and/ or sign post those at risk to GP or other suitable services. From year one of the strategy, all dentists will have cancer checks written into their contracts as standard. Additionally pharmacies are required to promote 6 health marketing campaigns per year in stores: ensuring a percentage of these are cancer related provides an ideal opportunity to promote messaging. Building on these already established healthcare touch points is an obvious way to deliver additional, life-saving, cancer information. The Be Clear on Cancer campaigns are nationally funded by Public Health England and occur three times per year. They are tested on the public before launch in order to ensure positive patient experience. These campaigns are therefore ready to implement and the recent lung cancer campaign has shown to increase two week referral rates 22. In addition to health care, there are also numerous touch points that individuals regularly come into contact with from adult and social care service managers in local authorities, to hairdressers, beauticians and taxi drivers. Again, exploring how London can use these already well-established touch points offers innovative ways of disseminating information. Case study Get to know cancer activist programme The Get to know Cancer activist programme trains local volunteers to be able to talk about cancer signs and symptoms and the importance of early detection. In December 2013 the programme trained twenty service managers from Redbridge Council who work with elderly people and those with learning difficulties. As age is a risk factor in developing cancer and evidence shows that people with learning difficulties are less likely to take up cancer screening, this is an ideal opportunity to disseminate messages through social care workers already coming into contact with members of the community. 2. GP delay Interventions tackling GP delay will improve the patient experience since patients will be referred more promptly, access diagnostics quickly and, where referred onto a diagnosis pathway, should reach that diagnosis more quickly. In the same way, 21 Evaluation of the Get To Know Cancer pop up shop initiative; 2013, Kings College London E. Scott1, L. Boyd2, E Wallace2, E. Ream1 & J. Armes1 E. Scott1, L. Boyd2, E Wallace2, E. Ream1 & J. Armes1 22 Cancer Research UK; Be Clear on Cancer evaluation Page 16 of 50

17 patient outcomes should improve as this will lead to diagnoses made at an earlier stage of the cancer. Supporting GPs to be able to spot signs and symptoms of cancer and refer appropriately and in a timely manner is key to reducing delays at the GP surgery. There are a number of tools that can be used to support GPs refer appropriately and promptly. Local GP leadership is vital to making sure these tools are received and embedded. This strategy recommends rolling out the existing practice profile programme that highlights nationally produced data on referral patterns and cancer incidence within a GP practice offering a useful learning and reflection tool for GPs. Evaluation has demonstrated a 3per cent increase in two week wait referrals in practices that had some form of intervention, including practice profile programmes in place 23. The Cancer Decision Support tool works with existing IT systems to log combinations of symptoms that patients present with and to flag to the GP where cancer is a possibility. This tool has been developed by Macmillan and early evaluation shows a positive result 24. Rolling this tool out to all practices across London would be an excellent support tool. The costs associated with roll-out are the costs of backfilling GP sessions in order to release them to receive training on the tool as well as the likely additional two week wait referrals. In 2012/13, three best practice commissioning pathways for the earlier detection of lung, ovarian and colorectal cancers were developed in order to support GPs to refer and to increase the speed at which a patient receives a diagnosis. CCGs have been asked to commission along these pathways. It is proposed two further pathways are developed to tackle those patients who present with vague abdominal symptoms that could relate to a number of different cancers. The current pathway sees patients referred along one pathway, e.g. colorectal, but if colorectal cancer is not found, the patient is referred back to the GP who needs to make a second assessment as to where the patient should be referred. A second pathway is also recommended which would improve referrals for patients presenting with blood in urine linked to kidney and bladder cancers. A pathway that supports patients to reach a diagnosis quickly no matter where their cancer originates will improve patient experience and outcomes. Direct access to diagnostics was a commitment made in the national strategy, Improving outcomes: A strategy for cancer 25, for: non obstetric ultrasound; chest X-ray; flexible-sigmoidoscopy; and, Brain Magnetic Resonance Imaging resources/~/media/files/circ/cancer/cancer%20cascade%20programme/cascade-london Greg-Rubin.ashx 24 Interim evaluation to be published in February Page 17 of 50

18 Progress has been made in London in ensuring all GPs have direct access to these diagnostics and this is included within contracts across London. It may be also be that other diagnostics are suitable for direct access in Primary Care, including CT scan for vague abdominal symptoms, and this strategy proposes developing clinical guidelines in year one as to when direct access for CT scan is appropriate. Molecular biomarkers are increasingly being researched meaning in future there may be an increase in the use of blood-based diagnostics which can be carried out in Primary Care settings. For commissioners, in the future, there may be further opportunities to commission diagnostics outside of the secondary care setting. 3. System delay Insufficient capacity in secondary care to meet rising referral demand can also play a role in delaying the time it takes to get a diagnosis. England s rates of endoscopy for lower gastrointestinal cancers per 100,000 population lag behind comparable countries. Endoscopy services themselves, also vary in quality with many not JAG accredited 26, the marker of a quality service, and some patients experiencing six plus and thirteen plus week waits for endoscopy. The impact of this is felt in England s poorer cancer outcomes for bowel cancer than in comparable countries. The introduction of Bowel scope will also increase demand on endoscopy for lower gastrointestinal cancers. Consequently developing and implementing a strategy for the endoscopy (colonoscopy and flexi sigmoidoscopy) is recommended as a priority for London. This will improve patient experience by reducing waiting times and ensuring every patient receives a quality assured endoscopy and will improve patient outcomes by accelerating diagnosis. Clinically-led recommendations have already been developed meaning this initiative is ready for commissioners to implement in year one of the strategy. It is also recommended that an endoscopy strategy for upper gastrointestinal cancers is developed and implemented due to the poor survival rates of these cancers and due to the lack of standards in endoscopy for upper gastrointestinal cancers. This work is in an early stage and therefore will not be ready for commissioners until year two of the strategy. 4. Targeted initiatives for high risk populations Across London, wide variations in cancer outcomes exist and inequalities persist in communities living side by side driven by factors including ethnicity, gender and socio-economic status. If London is to truly reduce variation and bring London s outcomes up to match best in world, it is recommended that targeted interventions are commissioned to reach high risk populations Page 18 of 50

19 The Cancer Awareness Measures delivered in London found that many people worried about wasting their GP s time and/ or could not make an appointment. Although there is great debate across London as to the appropriateness of direct access to secondary care, one option to overcome this could be the commissioning of rapid access clinics for high risk populations which would enable Londoners direct access to diagnostics. Further work needs to be done to identify whether this would be a suitable approach and if it would have impact. Smoking rates in some parts of London reach between 40 per cent and 60 per cent 27 depending on the local community. Lung cancer rates in women are also rising. Low dose CT scanning for populations at high risk of lung cancer is one option to identify early lung cancers prior to the development of lung cancer symptoms. This would have a positive impact on patient outcomes since resection for lung is dependent on the tumour being at an early stage. London Cancer is exploring whether it can pilot a CT screening programme; the National Screening Programme has also applied for funding to run a CT screening pilot for high risk populations. A final recommendation is for Hepatocellular Carcinoma Cancer (HCC) surveillance. Risk factors for HCC including chronic viral hepatitis and alcoholic liver disease; most of these risk factors lead to the formation and progression of cirrhosis, which is present in 80-90per cent of patients with HCC 28. Regular surveillance of at risk patients is aimed to detect HCC at an early enough stage where curative treatment is possible. Using traditional healthcare touch points in South West London to target health inequalities: the role of Pharmacy 43 pharmacies in areas of deprivation in Croydon, Wandsworth, Sutton and Merton participated in a direct access to chest x-ray pilot for customers at risk of lung cancer. Following training, counter staff were asked to offer a private consultation with the pharmacist to any customer aged over 50 with a smoking history, buying cough medicines, nicotine replacement therapy, collecting a prescription for antibiotics for a respiratory complaint or seeking advice about a respiratory complaint. Where patients met tailored NICE referral guidance, the pharmacist could refer the customer directly to a chest clinic. From 55 appropriate referrals made to the Chest clinic during the 6 month pilot, 47 customers accepted. Whilst no lung cancer was diagnosed, other significant diagnoses were made in 31 patients (66%) including 14 cases (30%) of moderate/severe COPD/emphysema. A key feature of the pilot was health promotion and increasing lung cancer awareness. All current smokers were offered a referral to a smoking cessation service. The pilot demonstrated very positive and promising results with regard to acceptability in both primary care and secondary care of direct access to a chest clinic. It also received positive feedback from pharmacy customers who reported that it was far easier to engage with pharmacists on the subject of lung cancer than their GPs and were impressed with the speed of the referral process. 27 As noted in London borough s JSNAs 28 Page 19 of 50

20 Assessment of the early detection and awareness interventions Early detection and awareness Intervention Patient outcomes Rapid access clinics for high risk populations CT scan for high risk population of lung cancer HCC surveillance Breast cancer over 70s Raise population awareness of specific signs and symptoms Utilising healthcare touch points Utilising non healthcare touch points Roll out of the Cancer Decision Support tool Managing procedures in community settings: skin lesion excision Greater access for GPs to CT scan for vague abdominal symptoms Development of best practice pathways Continual learning Primary Care Practice profiles Endoscopy for Lower GI Endoscopy for Upper GI Patient experience Readiness to deliver Notes Pilots in year one Pilots in year two Page 20 of 50

21 Guide For patient outcomes and experience: Green indicates high impact Amber indicates medium impact Red indicates low impact. For readiness for implementation by commissioners: Green indicates readiness in year one Amber indicates readiness in year two Red indicates readiness in years three five of the strategy. Page 21 of 50

22 4. Reducing variation and service consolidation Recommendations for commissioners in years one and two: IOG guidance and best practice pathways It is recommended that CCG commissioners: - Commission along these best practice pathways in order to reduce variation and improve overall quality - Ensure all providers to reach IOG compliance through effective performance management of contracts. Breast cancer: It is recommended CCG commissioners: - Use contractual levers to improve performance along the 23-hour pathway. - Request trust action plans for implementing the 23 hour pathway Lung cancer It is recommended CCG commissioners and Primary Care commissioners: - Commission along the best practice early detection pathway for lung cancer to ensure greater numbers of lung cancers are diagnosed at a stage when they are suitable for a resection. It is recommended CCG commissioners: - Request Trust action plans as to how they will increase resection rates - In North Central and North East London are recommended to identify contractual levers to increase use if laparoscopic techniques. Colorectal cancer It is recommended CCG commissioners: - Request Trust action plans to improve laparoscopic surgery rates - Look at contractual levers to drive up usage of laparoscopic surgery - Commission along the best practice guidelines to reduce variation in colorectal resections, improving patient experience, outcomes and reducing cost. Acute Oncology Services (AOS) It is recommended CCG commissioners: - Ensure compliance of provider organisations with peer review metrics for AOS in order to increase quality of services. Diagnostics It is recommended CCG commissioners: - Commission along the RCR and RCGP recommendations to increase the reporting time for diagnostic tests. Reconfiguration of services for rarer cancers It is recommended CCG commissioners: - Support the development of plans on the proposed reconfigurations to improve services in North Central and North East London Page 22 of 50

23 As the Case for Change demonstrated, London experiences significant variation in the incidence and mortality rates of cancer patients across London with inequalities in access and outcomes. Both Integrated Cancer Systems (ICSs) have worked together to develop a plan for reducing variation and service consolidation for London. Both London Cancer Alliance and London Cancer have provided assessments of where Trusts in their patch were performing against recommendations which led to the examples for recommended interventions. There is consensus from both ICSs on the recommended areas of intervention. Best practice guidelines are being developed by both ICSs and both will have published these by the end of March Each pathway aims to ensure Trusts are compliant with national IOG and, whilst more work is needed to fully understand what needs to be done to achieve this, commissioners can support with their implementation. The most common cancers in London have been prioritised in the first instance because of the potential to improve patient outcomes and patient experience for larger numbers of Londoners. Additionally, London Cancer has focussed primarily on rarer cancers such as brain and CNS, urology, head and neck and specialist haematology due to significant gaps in meeting existing NICE IOG compliance. London Cancer s clinicians have made recommendations to commissioners for how services could be changes in order to improve outcomes which are now being considered. For other areas, work is continuing to develop the thinking for less common and rarer cancers and will make recommendations to commissioners at a later stage. Key recommendations from the common cancers where work has been prioritised are summarised: 1. Breast cancer In 2012, there were 4876 diagnoses of breast cancer in London 29 and breast cancer is the most common cancer in the UK. London Cancer Alliance has already published clinical guidelines on breast cancer. 23-hour mastectomy Experiences vary for women in terms of the length of stay in hospital they will have for a mastectomy. The standard approach for surgery for breast cancer should follow a 23-hour pathway unless there are clinical reasons to justify exceptions. However there is variation in the percentage of women who will receive the 23-hour pathway ranging from 44 per cent to 96.4 per cent across London s providers ENCORE; Cancer Analysis System, 2012 figures 30 NCIN cancer commissioning toolkit National breast service profile Page 23 of 50

24 By reducing this variation, 500 extra women could receive the 23-hour pathway and associated reduction in bed days and improved patient experience. Whilst this will not drive a cost saving for commissioners through reduced length of stay, this initiative will improve patient outcomes, patient experience and improve provider efficiency. Timely access to breast reconstruction Post mastectomy, best practice requires all women to have the opportunity to discuss their breast reconstruction options and have immediate breast reconstruction where appropriate. Provider networks should be set up to facilitate every patient being offered reconstruction in a specialist centre. Again there is evidence of wide variation in the numbers of women being offered immediate reconstruction to enable every patient to have the choice. This initiative is prioritised for the improved patient experience and should be cost neutral to commissioners since activity is only brought forward by women having breast reconstruction sooner and is not expected to increase. Management of metastatic disease There is variation in how patients are treated when there is a suspicion of metastatic breast cancer. Patients with recurrent or metastatic breast cancer should receive multidisciplinary care and the support of a CNS, as outlined in the NICE breast quality standard but there is little evidence to the current baseline of practice. Bringing every trust up to the optimal can only serve to improve both patient outcomes and experience as metastatic diagnosis is reached quickly and the patient reviewed by the appropriate clinical team. Year one of this work is therefore to understand current practice across the ICSs with a view to in year two being able to implement standardisation. 2. Lung cancer 3724 Londoners were diagnosed with lung cancer in Alarmingly lung cancer rates are increasing in women in many London boroughs 32. The National Lung Cancer Audits have identified the variation in lung resection rates across England and this is in addition to the already low base number when compared to European counterparts. Increasing lung resection rates Evidence suggests that higher lung resection rates can increase lung cancer survival and that lung cancer survival could increase if a larger proportion of patients underwent surgical resection 33. The variation in resection rates for lung cancer patients treated across London s provider organisations shows rates ranging from 31 ENCORE; Cancer Analysis System, 2012 figures 32 As noted in Joint Strategic Needs Assessments across London 33 Riaz et all 2011 Page 24 of 50

25 2.4per cent to 31per cent 34. Whether a resection occurs or not depends on both the stage of diagnosis and the input of thoracic surgeons at all lung MDTS, this initiative therefore links to the best practice commissioning pathway for the earlier detection of lung cancer which will be implemented in year one of this strategy. London Cancer laparoscopic surgery for lung cancer London Cancer has additionally prioritised laparoscopic surgery for lung cancer as a minimally invasive technique. Lung cancer treatment in the over 70s Evidence shows that the over 70s are less likely to receive active treatment for lung cancer 35. However there is currently little known about the rates of active treatment given across London. Work is required to understand both the treatment options offered to this cohort of patients and the factors that impact on treatment choices. Therefore overall readiness is low for year one of the strategy, but generally greater emphasis on ensuring consistency of care for the elderly will be an important area in the period of this strategy. NB. It is likely this will apply to all recommendations. 3. Colorectal Cancer 3463 Londoners were diagnosed with colorectal cancer in Between 1971 and 2008, incidence rates for colorectal cancer increased by 33per cent for men and 12per cent for women. In 2008, colorectal cancer accounted for 14per cent of all new cancer diagnoses in men (57 new cases per 100,000 population) and 12per cent in women in England (37 new cases per 100,000) 37. Laparoscopic surgery Laparoscopic colorectal surgery allows faster recovery from surgery for patients suitable for this technique, therefore reducing bed days and improving patient experience. If patients are deemed suitable for both laparoscopic surgery and open surgery, NICE recommends laparoscopic surgery is performed. Across London, the laparoscopic rate varies significantly across the provider organisations from 11per cent to 84per cent Lung cancer resection rates for patients in 2012; LUCADA 2013 report 35 Age, comorbidity, treatment decision and prognosis in lung cancer; Oxford Journals ENCORE; Cancer Analysis System, 2012 figures Laparoscopic resection rates 2011/12; NBOCAP audit report 2013 Page 25 of 50

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